Health care providers' missed opportunities for preventing femicide

BACKGROUND

Homicide of women (femicide) by intimate partners is the most serious form of violence against women. The purpose of this analysis of a larger multisite study was to describe health care use in the year prior to murder of women by their intimate partner in order to identify opportunities for intervention to prevent femicide.

METHODS

A sample of femicide cases was identified from police or medical examiner records. Participants (n = 311) were proxy informants (most often female family members) of victims of intimate partner femicide from 11 U.S. cities. Information about prior domestic abuse and use of health care and other helping agencies for victims and perpetrators was obtained during structured telephone interviews.

RESULTS

Most victims had been abused by their partners (66%) and had used health care agencies for either injury or physical or mental health problems (41%). Among women who had been pregnant during the relationship, 23% were beaten by partners during pregnancy. Among perpetrators with fair or poor physical health, 53% had contact with physicians and 15% with fair or poor mental health had seen a doctor about their mental health problem. Among perpetrators with substance problems, 5.4% had used alcohol treatment programs and 5.7% had used drug treatment programs.

CONCLUSIONS

Frequent contacts with helping agencies by victims and perpetrators represent opportunities for the prevention of femicide by health care providers.

Abuse assessment screen-disability (AAS-D): measuring frequency, type, and perpetrator of abuse toward women with physical disabilities

An interview questionnaire was presented to a multiethnic sample of 511 women, age 18-64 years, at public and private specialty clinics to determine the frequency, type, and perpetrator of abuse toward women with physical disabilities. The four-question Abuse Assessment Screen-Disability (AAS-D) instrument detected a 9.8% prevalence (50 of 511) of abuse during the previous 12 months. Using two standard physical and sexual assault questions, 7.8% of the women (40 of 511) reported abuse. The two disability-related questions detected an additional 2.0% of the women (10 of 511) as abused. Women defining themselves as other than black, white, or Hispanic (i.e., Asian, mixed ethnic background) were more likely to report physical or sexual abuse or both, whereas disability-related abuse was reported almost exclusively by white women. The perpetrator of physical or sexual abuse was most likely to be an intimate partner. Disability-related abuse was attributed equally to an intimate partner, a care provider, or a health professional. This study concludes that both traditional abuse-focused questions and disability-specific questions are required to detect abuse toward women with physical disabilities.

Severity of violence against women correlates with behavioral problems in their children

In order to examine the type and severity of violence against women by intimate partners and the associated behavioral problems of their children, 83 abused women were interviewed when they presented to the criminal justice system for protective orders or to file assault charges. Two questionnaires were administered: (a) the 46-item Severity of Violence Against Women Scale (SVAWS) measured threats of abuse and actual physical violence, and (b) the 118-item Child Behavior Checklist (CBCL) measured child behavior problems for children between the ages of 4 and 18.

Views of nurses, patients and patients' families regarding palliative nursing care

This article presents the findings of a 3-phase project, that used the qualitative approach of storytelling to examine the degree of congruency between the perceptions of nurses, patients and patients' families respectively, in relation to the nature and effects of palliative nursing care. The major difference in the stories was the slight emphasis on the personal qualities palliative nurses bring to their work and the activities in which they engage. Nurses emphasized their work activities, whereas patients and relatives gave equal emphasis to the positive and negative aspects of nurses' qualities and activities.

Intimate partner violence. Mothers' perspectives of effects on their children

PURPOSE

Intimate partner violence not only affects adults but also the children living within that "war zone." The present study expands our understanding about how children are affected when they observe violence in their own homes, as reported by their mothers.

STUDY DESIGN

This descriptive study was conducted to describe mothers' perspectives of the impact of the violence on their children. A consecutive sample of 72 mothers attempting to file assault charges were interviewed in a private room by a registered nurse and were asked to describe the effect of witnessing intimate partner violence on their child's behavior. Each response was written verbatim by the interviewer.

RESULTS

A majority (72%) of the mothers reported negative behaviors in their children that they believed were as a result of witnessing their mother's violent experiences. The most common negative traits were distress-indicating behaviors such as sleep disturbances, clinging, and fretful behaviors followed by problems with the abuser, problems in school, and problems with mother.

CLINICAL IMPLICATIONS

Because intimate partner violence affects children, health care providers should become familiar with behaviors indicative of this problem. To promote the well being and development of children, recommendations for assessment and intervention for women experiencing intimate partner violence are discussed.

Referring abused women: does police assistance decrease abuse?

To evaluate if abused women's use of the police reduced further violence experienced, 90 abused women were interviewed at a large urban police department and followed for 6 months. Frequency and severity of violence as well as danger of homicide were measured before and at 3 and 6 months after women sought police help. Women seeking police help had significantly reduced threats of abuse (F = 124.62, df = 2,81; p < .0005), actual abuse (F = 90.11, df = 2,81; p < .0005), and danger of being killed (F = 188.69, df = 2,81; p < .0005) by her intimate partner. Bonferroni post hoc tests showed that significantly fewer threats of abuse, physical abusive acts, and risk indicators for homicide had occurred from prefiling to 3 months (p <.0005) and prefiling to 6 months (p <.0005). The data indicate that referring abused women to the police is an appropriate intervention.

Women in danger: intimate partner violence experienced by women who qualify and do not qualify for a protective order

Not all women who apply qualify for a civil protective order. This study compares the type and severity of violence reported by women who qualified with that experienced by women who did not qualify. Ninety women seeking a protective order against a male intimate were interviewed. Findings indicated that 28% of women applying for a protective order did not qualify primarily because of cohabitation requirements or childbearing status. Actual and threatened violence was measured with the 46-item Severity of Violence Against Women Scale. A 17-item questionnaire measured stalking behavior. Levels of reported violence for the preceding 3 months were measured for the two groups. The symbolic threat behavior only of throwing, smashing, or breaking an object was significantly higher for qualifying women. The physical abuse behavior only of being pushed, shoved, or pulled was significantly higher. None of the stalking behaviors were significantly different. Data are urgently needed that document the barriers to abused women receiving protective orders, the relevancy of qualifying criteria, and the effectiveness of protective orders issued.

An evaluation of interventions to decrease intimate partner violence to pregnant women

Prevention of abuse to women is a national priority; however, research has focused on identification of abuse rather than evaluating interventions. To evaluate the differential effectiveness of three levels of intervention, Brief, Counseling, and Outreach, a longitudinal study with repeated evaluation interviews at 2-, 6-, 12-, and 18-months postdelivery was completed at two urban public health prenatal clinics. The participants were 329 pregnant, physically abused Hispanic women. Both physical abuse and women's use of community resources were measured. Repeated measures ANOVA showed that severity of abuse decreased significantly (p < 0.001) across time for all intervention groups. Violence scores at 2-months postdelivery were significantly lower for the Outreach group (p < 0.05) compared to the Counseling only group, but not significantly lower than the Brief intervention group. At 6-, 12-, and 18-month follow-up there were no statistically significant differences among the intervention groups. The use of lay outreach for abused pregnant women merits further research. Abuse screening by itself, however, may be the most effective intervention to prevent abuse to pregnant women.

Indicators of intimate partner violence in women's employment: implications for workplace action

The study examined the indicators and consequences of intimate partner violence on women's employment and associated types and levels of violence. Interviews were conducted with a consecutive sample of 90 women seeking a protective order. Actual and threatened violence was measured with the Severity of Violence Against Women Scales (46 items). Eight questions were asked about type of harassment experienced at the worksite. The results found most of the abused women had been employed at one time (87%) and had also experienced harassment from an intimate partner related to their work (89%). Findings indicated lost productivity and reduced performance. The researchers concluded poor work performance, tardiness, and absenteeism may indicate an employee is suffering from intimate partner violence.

Successful ECT in a case of Leonhard's cycloid psychosis

In Leonhard's nosological system, acute, episodic psychoses with good short-term and long-term prognoses, characterized by mixed affective and schizophrenic features, confusion, and alternating psychomotor retardation and excitement are called cycloid psychoses. According to clinical lore, patients with cycloid psychoses show an excellent and prompt response to electroconvulsive therapy (ECT). We describe a patient with typical motility psychosis, a subtype of cycloid psychoses, who failed to respond to a combination of antipsychotic and benzodiazepine medication but quickly recovered after the administration of ECT.

Mandatory reporting of intimate partner violence: safety or retaliatory abuse for women?

We wished to ascertain abused women's perspectives on mandatory reporting of intimate partner violence. A consecutive sample of 161 abused women accessing the criminal justice system were asked six questions. Most women (81%) thought there should be a law making the nurse or doctor report the abuse, with less than half of the women (45%) reporting they would have been at greater risk for abuse following a mandatory report. Although these 161 abused women support mandatory reporting of partner abuse, it remains unclear if such a law would deter further abuse. Outcome and evaluation studies of mandatory reporting laws are urgently needed.

Making a difference with dying people: positive nurse-patient interactions

This paper presents some of the qualitative findings from a recent research study, which explored the nature and effects of palliative nursing care for patients. By using story telling as the research methodology, the participants related their positive experiences about palliative care nursing. The results of the research indicated that there was a strong link between positive experiences and effective nurse-patient interactions. The characteristics and the results of these interactions are presented in this article. The article concludes with a discussion of the potential ethical problems of assessing palliative care patients suitability for research.

The effectiveness of an abuse assessment protocol in public health prenatal clinics

OBJECTIVES

This study evaluated whether incorporation of an abuse assessment protocol into the routine procedures of the prenatal clinics of a large urban public health department led to increased referral for and assessment, identification, and documentation of abuse.

METHODS

Evaluation was conducted at 3 matched prenatal clinics serving a total of 12,000 maternity patients per year. Two clinics used the abuse protocol and 1 did not. An audit was performed at the clinics on a randomly selected sample of 540 maternity patient charts for the 15 months before the protocol was initiated and of 540 records for the 15 months after the protocol was introduced. Ninety-six percent of the patients represented in the sample were Latina.

RESULTS

At the clinics using the protocol, abuse assessment increased from 0 to 88%. Detection of abuse increased from 0.8% to 7%. There were no changes at the comparison clinic.

CONCLUSIONS

Incorporation of an abuse assessment protocol into the routine procedures of public health department prenatal clinics increases the assessment, identification, and documentation of and referral for abuse among pregnant women. An abuse protocol should be a routine part of maternity care.

Use of counseling by abused pregnant Hispanic women

The purpose of this study was to determine if there are characteristics of abused women that are associated with the women's use of the services of counseling to help end the abuse. The research design was a prospective, descriptive analysis of 216 abused pregnant Hispanic women receiving prenatal care in urban public health clinics. Women who were abused by their intimate male partner were offered unlimited access to the services of a bilingual English/Spanish-speaking counselor experienced in abuse whose office was located in the public health clinic. Baseline demographic characteristics, severity of abuse experienced by the women, and the women's previous use of community resources were assessed. Analyses were conducted to examine associations between baseline characteristics and the number of visits the abused women made to the counselor. The results of the study show that when an abused pregnant Hispanic woman had an average of two or more children, she was more likely to use the services of an abuse prevention counselor. The study also showed that the women who had used the police most during the previous 12 months made the fewest number of visits to the counselor. Prenatal care may provide a convenient and safe setting for low-income, ethnic minority women with numerous children to conveniently and safely access abuse prevention services. Research is needed on the effectiveness of incorporating abuse intervention services into nontraditional settings, such as neighborhood clinics.

Severity of abuse before and during pregnancy for African American, Hispanic, and Anglo women

OBJECTIVE

To describe timing and severity of abuse before and during pregnancy for African American, Hispanic, and white Anglo American women.

FINDINGS

Among 199 abused women, 18.1% of the women were abused during pregnancy but not the year before, 30.2% were abused the year before but not during pregnancy, and 51.8% were abused both the year before and during pregnancy. The timing of abuse did not vary by ethnicity. The three (ethnicity) by three (timing) factorial analysis of variance showed severity of abuse to vary by timing of abuse. Women reporting abuse both before and during pregnancy reported greater severity of abuse on each of the five measures than did women abused only before pregnancy or only during pregnancy.

CONCLUSIONS

Over half (51.8%) of the women reported abuse before and during pregnancy with these women reporting greater severity of abuse on all five severity scores. Timing and severity of abuse did not vary by ethnic group. The majority of women abused during pregnancy were also abused prior to pregnancy, indicating the need for universal screening of all women during each health encounter.

Testing an intervention to prevent further abuse to pregnant women

Although violence against women is recognized as a major public health problem, few interventions have been developed to reduce abuse. In this study, 132 pregnant women received three counseling sessions that were designed to reduce further abuse. A comparison group of 67 abused women were offered wallet-sized cards listing community resources for abuse. Women in both groups were followed at 6 months and 12 months post-delivery. Using repeated measures MANCOVA with entry scores as a covariate, we found significantly less violence reported by women in the intervention group than by women in the comparison group.

Weight change of infants, age birth to 12 months, born to abused women

Abuse to pregnant women can affect maternal health and infant birthweight. To examine the rate of weight change among infants, ages birth to 12 months, born to women abused by the male intimate, an ethnically stratified cohort of 121 infants and their mothers were followed. Infants were weighed on a beam balance scale at birth, 6, and 12 months of age. At the same time, abused mothers were asked if the abuse had ended. Rate of change in infant weight was calculated for birth to 6 months and 6 months to 1 year. The rate of change in infant weight from birth to 6 months did not differ significantly based on whether or not the mother reported that the abuse had ended by 6 months or 12 months. However, the rate of change in infant weight from 6 to 12 months was significantly greater (p = .046) for those infants whose mothers reported the abuse had ended by 12 months and even greater (p = .019) if the mother reported that the abuse had ended by 6 months. When controlling for ethnicity and parity, abuse ending at 6 months was a significant (p = .029, r2 = .102) predictor of the rate of infant weight change from 6 to 12 months. To maximize infant growth and the health and wellbeing of mother and child, routine screening and intervention for abuse of women is recommended during child health visits.

Predicting physical abuse against pregnant Hispanic women

CONTEXT

Abuse during pregnancy is common and has adverse health effects on maternal and infant health. To prevent abuse to pregnant women, predictors must be identified and incorporated into routine screening and intervention protocols.

OBJECTIVE

To investigate whether or not symbolic violence and threats of violence by a male intimate were associated with physical violence against pregnant Hispanic women.

DESIGN

Cross-sectional interview survey questionnaire.

SETTING

Urban, public health prenatal clinics.

PARTICIPANTS

329 pregnant, physically abused Hispanic women.

MAIN OUTCOME MEASURE

Physical abuse against pregnant Hispanic women as measured on the Severity of Violence Against Women Scale.

RESULTS

Regression analysis showed that symbolic violence and threats of violence by the perpetrator were jointly and independently significantly (P < .0005) associated with physical violence.

CONCLUSIONS

Because symbolic violence is significantly associated with physical violence against pregnant women, screening and early intervention programs should focus on such behavior.

Severity of spousal and intimate partner abuse to pregnant Hispanic women

Abuse to pregnant women can result in complications to maternal and child health. This study assessed the severity of intimate male partner abuse to Hispanic pregnant women receiving prenatal care at an urban public health department. The mean age of the 329 pregnant, abused Hispanic women was 24 years. The women had an average of eight years of education, annual incomes of less than $10,000, and most spoke only Spanish. In all, 30 percent of the women had been threatened with death, 18 percent had been threatened with a knife or gun, 80 percent had been shaken or roughly handled, 71 percent pushed or shoved, and 64 percent slapped on the face and head. Pregnant, abused Hispanic women experience abuse of sufficient severity to pose a risk to maternal and child health. Prenatal care provides a window of opportunity for routine abuse assessment and counseling for low-income, Hispanic pregnant women.

Characteristics of sexual abuse against pregnant Hispanic women by their male intimates

There have been few research reports on sexual abuse of Hispanic women by their intimate male partners. This study examined the frequency of six types of sexual abuse of 329 pregnant Hispanic women identified during routine prenatal care in public health clinics as physically abused. Threats of abuse, physical abuse, and sexual abuse were measured with the 46-item Severity of Violence Against Women Scale. Comparisons were made between women reporting sexual abuse and those who did not. Thirty-two percent (n = 105) of the women reported sexual abuse by their male partner at least once during the prior 12 months. Sexually abused women reported significantly higher levels of threats of abuse and physical abuse than women not sexually abused. Among the sexually abused women, not living with the abuser was correlated with higher threats of abuse, physical violence, and sexual abuse scores. The results of this study support previous research proposing a continuum of violence and possible escalation of violence when an abused woman leaves her abuser. Additional longitudinal research is needed on psychosocial and behavioral characteristics of sexually abused women, particularly among ethnic minority women.

Severity of abuse to pregnant women and associated gun access of the perpetrator

To investigate the relationship between abuse to pregnant women and gun access by the abuser, an ethnically stratified cohort of 199 pregnant abused women (70 African-Americans, 63 non-Hispanic Anglo-American, and 66 Hispanic women were interviewed using: (1) The Index of Spouse Abuse, a measure of the severity of physical and nonphysical abuse; (2) The Danger Assessment Scale, a measure of potential danger of homicide; and (3) The Severity of Violence Against Women Scale, a measure of threats of violence and actual violence. There were no significant differences by ethnicity among the 41.2% of the abused women who reported that their male partner had access to a gun. Among these same women reporting gun access, 17% reported the abuser kept the gun on his body. Women reporting gun access by the abuser reported higher level of abuse on all scaled instruments (P = < 0.01). To protect women's safety and prevent further trauma and potential homicide, routine assessment for abuse and gun access is recommended. Additionally, policy initiatives to remove firearms from abuse perpetrators may reduce the severity of violence experienced by abused women.

Long-term suprapubic catheterisation: clinical outcome and satisfaction survey

We report on the clinical outcome and satisfaction survey of long-term suprapubic catheterisation in patients with neuropathic bladder dysfunction. Between early 1988 and later 1995, 185 suprapubic catheters were inserted under direct cystoscopic vision. Anti-cholinergic therapy was given to all patients with significant detrusor hyper-reflexia; the catheters clamped daily for two hours and changed every six weeks. Ultrasonography and assessment of the serum creatinine were used to assess the upper renal tracts, and the results of the pre- and post-catheter video-cystometrography was used to evaluate bladder morphology, cystometric capacity, maximum detrusor pressure and the presence of vesico-ureteric reflux. There were equivalent numbers of males and females. The follow-up ranges from 3-68 months. Following catheterisation, there was a 50% reduction in the average maximum detrusor pressure, bladder morphology improved in 85% of the cases; the bladder capacity and upper renal tracts remained unchanged. Vesico-ureteric reflux was abolished in 33% of the cases. Complaints were common consisting of recurrent catheter blockage, persistent urinary leakage and recurrent urinary tract infections. There was a 2.7% incidence of small bowel injury with one fatality. However, the general level of satisfaction was high. It is concluded that suprapubic catheterisation is an effective and well tolerated method of management in selected patients with neuropathic bladder dysfunction for whom only major surgery would otherwise provide a solution to incontinence. We are encouraged to find preservation of renal function with maintained bladder volumes and reduced maximum detrusor pressures thus justifying the policy of catheter clamping and anti-cholinergic therapy in the presence of significant detrusor hyper-reflexia. However, even in expert hands this procedure is not without hazards.

Violent pornography and abuse of women: theory to practice

To examine violent pornography use and associated violence against women, an ethnically stratified sample of 198 abused women were asked about their partners' use of pornographic materials, and if they had been asked or forced to look at, act out, or pose for pornographic scenes or pictures. Overall, 40.9% of the women reported the abuser used pornographic material, with the proportion significantly higher for Whites (58.7%), compared to Blacks (27.1%) or Hispanics (38.5%). When groups were formed according to the abuser's use of pornography and associated involvement of the woman, violence scores as measured on the Index of Spouse Abuse, Danger Assessment, and Severity of Violence Against Women scales were significantly higher (p = <.001) for women reporting the abuser requested or forced her to look at, act out, or pose for pornographic scenes. Severity of violence was not related simply to whether or not the abused used pornography. This analysis is a beginning step toward understanding how pornography influences woman abuse.

Safety behaviors of abused women after an intervention during pregnancy

OBJECTIVE

To evaluate an intervention protocol, administered during pregnancy, for increasing safety-seeking behaviors of abused women.

DESIGN

Prospective, ethnically stratified cohort analysis.

SETTING

Public prenatal clinics.

PARTICIPANTS

Pregnant women reporting physical or sexual abuse in the year before or during the present pregnancy. One hundred thirty-two women met study criteria, received the intervention, and were followed for 1 year after the completion of the pregnancy.

INTERVENTION

Three education, advocacy, and community referral sessions that included information on safety behaviors.

MAIN OUTCOME MEASURE

Adoption of safety behaviors by abused women. Safety behaviors were measured before the intervention, twice during pregnancy, and at 2, 6, and 12 months after completion of the pregnancy.

RESULTS

Repeated measures analysis of variance showed a significant increase in adoption of each safety behavior (p < .0001), with most behaviors showing a significant increase after the first intervention session.

CONCLUSIONS

Pregnant women who were abused and were offered an intervention protocol report a significant increase in safety behavior adoption during and after pregnancy. Abuse during pregnancy is common. Identification of abuse and immediate clinical intervention that includes information about safety behaviors can result in safety behavior adoption that may prevent future abuse and increase the safety and well-being of women and infants.